Learning from Experience – Intra Operative, Chapters 31 and 32

INTRA-OPERATIVE

Chapter 31

Pulmonary Oedema following Hysteroscopy

Dr. Vasanthi Vidyasagaran

Department of Anaesthesiology, Kauvery Hospital, Chennai,

Tamilnadu, India

A 28-year-old woman was posted for hysteroscopic removal of a fibroid polyp in a day-care setting. On pre-operative examination, she was anaemic with haemoglobin of 7 gm/dl. All other investigations were within normal limits. She was taken up for the procedure in spite of low haemoglobin, as the cause for anaemia was bleeding from the polyp. Two units of packed cells were ready for transfusion. The plan was general anaesthesia with controlled ventilation.

After induction of anaesthesia, she was placed in lithotomy position. Procedure was commenced. The surgical team faced a lot of technical difficulties with respect to their instruments. There were leaks in the hysteroscope, and malfunctioning light source. It was anticipated that the procedure would be completed in 45 minutes to an hour. However, it lasted for nearly 3 h.

Towards the end of the procedure, the patient began to desaturate. On manual ventilation, the bag was tight and auscultation revealed bilateral crepitations. No time was lost in diagnosing the condition as pulmonary oedema. Immediately 40 mg Frusemide was given, the patient was catheterized and ventilated with CPAP. After one hour of ventilation she was reversed. She was breathing spontaneously, but desaturating with room air. Hence, ventilation was maintained with continuous positive airway pressure for the next one hour with 100% oxygen. She was haemodynamically stable. Once the chest was clear on auscultation, she was extubated. She recovered without any further complications.

On reviewing the situation, it was realized that 15 L of Glycine had been used during the time span of the procedure. The surgeon was under the impression that most of it had leaked out. Attention of the theatre personnel was diverted towards the faulty equipment and there was no actual measurement of how much fluid was wasted or absorbed into the circulation. The anaesthetist was not familiar with the procedure. It was difficult to judge the volume of fluid absorption. Root cause analysis of such critical incidents must happen to prevent them happening ever again. Theatre personnel were educated, and protocols to measure irrigation fluid which was already there was reinforced. Patient was anaemic and this could also have been a contributory factor in precipitating pulmonary oedema.

Discussion

Hysteroscopy requires distention of the uterine cavity for visualization of the operative field. 1.5% Glycine is a widely-used distention medium because of its optical properties and non- conductivity. Intraoperative absorption of this electrolyte-free fluid can cause hyponatraemia, hypo osmolality, hyperglycaemia and volume overload, including pulmonary oedema. One must be able to recognize signs of glycine intoxication early and treat the condition by:

Supportive measures, ventilation, maintaining fluid balance and haemodynamics.

IV hypertonic saline (commonly 3%), when Na+ levels are <120 mmol/L, at rate of <1 mmol/L/hour, as rapid correction may result in osmotic demyelination, (previously called central pontine myelinosis).

IV Furosemide to treat acute pulmonary oedema

Measurement of fluid absorption however remains difficult. Fluid deficit should be calculated at least every ten minutes. Factors deciding the degree of fluid absorption are extent of transection of vascular beds, intrauterine distention pressures, duration of the procedure and surgical experience. Automated electronically controlled irrigation-suction pump may help in guiding the amount of fluid infused and warning signals be provided when crossing the limit.

Operative hysteroscopy intravascular absorption (OHIA) syndrome has been well recognized and is similar to TURP syndrome. In gynaecological surgery, fluid absorbed during a hysteroscopic fibroid resection will be much more than TURP, since, in addition to being absorbed by the vessels, it can also enter the peritoneal cavity by the patent fallopian tubes. Pre-menopausal women are at higher risk for neurologic sequelae from even modest hyponatraemia, as sex hormones adversely affect the sodium pump in brain cells leading to cerebral oedema.

As preventive measures:

(1) Stop surgery if fluid deficit > 1000 ml, check sodium levels.

(2) Restrict time of procedure to 60 min, prophylactic frusemide may be indicated if time > 60 min.

(3) Regional anaesthesia may be preferred, because awake patients are likely to display clinical symptoms. They may complain of restlessness, headache, and visual disturbances. Bradycardia/tachycardia, hypotension and decreasing oxygen saturation are early signs of pulmonary oedema.

(4) In patients under GA, close watch on fluids and electrolytes are essential. References

[1] Hepp P, et al. Rapid correction of severe hyponatremia after hysteroscopic surgery – a case report. BMC Anaesthesiol. 2015;15:1.

[2] Sethi N, et al. Operative hysteroscopy intravascular absorption syndrome: A bolt from the blue. Indian J Anaesth. 2012:56:179-182.

[3] Jackson S, et al. Operative hysteroscopy intravascular absorption (OHIA) syndrome. West J Med. 1995;162:53-4.

[4] Serocki G, et al. The gynaecological TURP syndrome. Severe hyponatremia and pulmonary oedema during hysteroscopy. Anaesthesist 2009;58:30-4.

[5] Hahn RG. Fluid absorption in endoscopic surgery. Br J Anaesth 2006;96:8-20.

Chapter 31

Tracheo -Oesophageal Fistula (TEF) following battery ingestion

A 6-year-old child was brought into the hospital with history of button battery ingestion

2 days ago. The parents had waited for it to pass via the gastrointestinal tract. However, the child began to develop persistent irritant cough and refused food intake. Hence, he was brought to the hospital.

On examination lungs were clear. Chest x-ray revealed a button battery lodged in the mid- oesophagus level. No other abnormality was detected. It was planned to perform an oesophagoscopy under general anaesthesia to remove the foreign body.

General anaesthesia was induced with Propofol, and Suxamethonium was used as muscle relaxant, as the procedure is usually done within 5 to 10 minutes. Trachea was intubated with size 5.0 ETT. During oesophagoscopy, it was found that the battery had leaked and caused damage to oesophageal wall. The corrosive injury extended up to the trachea. Diagnosis of trachea-oesophageal fistula was made. Anaesthesia was deepened with sevoflurane, and 15 mg atracurium was given, and the tube was pushed beyond the fistula.

Fistula repair had to be done at the same sitting after obtaining consent from the parents. Fortunately, the fistula was not very big, and closure was done without any major problem. We also speculate that because the rent in trachea was small, positive pressure ventilation in the beginning in an undiagnosed TEF did not cause any subcutaneous emphysema or mediastinal damage. Child recovered well.

Early diagnosis during oesophagoscopy prevented major complications. Thoracic epidural was given for postoperative pain relief. Child was shifted to ICU and he made an uneventful recovery.

Discussion

Most cases of disc battery ingestion run uneventful courses, but some may be complicated. If the battery lodges in the oesophagus, emergency endoscopic management is necessary.

However, once the foreign body moves into the stomach, it will usually pass through the GI tract, but a follow up is required. Cases have been reported in children and adults.

Removal of foreign body in trachea or oesophagus can be challenging depending on position, impaction, mucosal wall damage, atresia, fistula, and duration of impaction on wall. Anaesthesia for such cases may not be simple.

It is a situation of shared airway, we must be prepared and well equipped for management of any major intervention. Manipulation of the endotracheal tube during the procedure may be required. Vigilant monitoring throughout the procedure is mandatory.

Removal of a FB from the oesophagus may be minor, but the family may not be aware that the same can become a major procedure if complications arise such as in this child requiring TEF repair involving thoracotomy. This must be discussed with the family prior to the procedure and consent obtained for the same.

References

[1] Tabari AK, et al. Tracheoesophageal fistula following disc battery ingestion and foreign body impaction. Caspian J Intern Med. 2011; 2(4): 336-9.

[2] Grisel JJ, et al. Acquired tracheoesophageal fistula following disc-battery ingestion: can we watch and wait? Int J Pediatr Otorhinolaryngol. 2008;72(5):699-6.

[3] Chang YJ, et al. Clinical analysis of disc battery ingestion in children. Chang Gung Med J. 2004;27:673-7.

[4] Conners GP, Mohseni M. Paediatrics, Foreign Body Ingestion. StatPearls 2010.

[5] Petri NM, et al. Esophagotracheal fistula after lithium disc battery ingestion successfully treated with hyperbaric oxygen therapy. Int J Pediatr Otorhinolaryngol. 2003;67:921-6.

[6] Khaleghnejad Tabari A, et al. Tracheoesophageal fistula following disc battery ingestion and foreign body impaction. Caspian J Intern Med. 2011;2:336-9.

Learning from Experience – Intra Operative, Chapters 31 and 32

INTRA-OPERATIVE

Chapter 31

Pulmonary Oedema following Hysteroscopy

Discussion

Chapter 31

Tracheo -Oesophageal Fistula (TEF) following battery ingestion

Discussion

References

Journals